Courage Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed the following quality statements: Shared Direction and Culture, and Governance, Management and Sustainability. Improvements were required to ensure the effective management and oversight of safeguarding, incidents and accidents, care plans, risk assessments and medicines. Improvements were needed to ensure safe recruitment practices were implemented as well as ensuring mental capacity assessments were correctly completed and staff training records were up to date. The processes in place to assure the quality of the service were not always effective and staff did not always feel supported in their roles by the management team.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received varied feedback from staff about the management and culture of the service. Some staff told us the management team were approachable, however other staff said they did not feel respected by the management team due to way they communicated with staff, and this affected the morale of the staff team.

The provider had implemented processes to involve people and staff in the running of the service. Regular feedback was sought from people and staff on the quality of the service. However, there was a lack of clarity in the questions asked in the questionnaires used for this purpose. For example, some of the questions in the questionnaires for people using the service could only be answered by a member of staff. The provider had sought feedback from staff at the end of 2023. Appropriate questions were asked but there was no option for staff to provide further information about scores they had awarded different areas of the service. This would make it difficult for the provider to fully analyse staff opinions and take action to drive improvement. The provider could not be confident the processes they had in place for monitoring the quality of the service were effective.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We received varied feedback from staff about the management arrangements in place at the service. Some staff told us the management team were responsive, and willing to listen to and act on any concerns received from people, staff, and stakeholders. However, some staff told us they did not feel listened to or supported when they brought concerns to the attention of the management team.

Governance processes were not effective at ensuring the quality and safety of the service. The systems in place had not resulted in timely improvement to the areas of concern found during the inspection. There was a lack of oversight of safeguarding incidents, accidents and incidents and complaints. Safeguarding referrals had not been made as required. There was poor governance and a lack of ongoing monitoring of care documentation. People's care plans and risk assessments contained incomplete information about people's risks and requirements. There was a risk people would not receive appropriate care to meet these needs. Oversight of medicines was ineffective, and systems had not been implemented to ensure people's medicines were administered safely. There was poor governance and oversight of people’s mental capacity assessments. Mental capacity records were not always completed correctly. Where care records confirmed people did not have capacity, no best interest decision had been completed. There was a lack of oversight of recruitment procedures and staff training records. Recruitment records were incomplete and the training matrix in place was not up to date. Mandatory training had not always been updated as required and not all staff had received the specialist training they required to meet people’s needs.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.